Travel health and people living with type 1 diabetes

Abstract

Type 1 diabetes (T1D) management can be particularly challenging when travelling, in view of changes to everyday routines, insulin thermostability and infectious disease exposure.^1-3 Furthermore, coping with health issues can be more complicated, because of the potential need to access specialised healthcare, equipment and medicines. Our recent review has highlighted the lack of quality-related data within the extant literature and need for consensus guideline development.² We undertook a study of people with T1D (PT1D) and current carers of PT1D (CCPT1D) to determine travel health knowledge, attitudes, practices, experiences and perceived needs around international travel.

A previously validated questionnaire⁴ was adapted to include international travel history, experiences and perceived needs; the appropriateness of the questionnaire to meet study aims was confirmed (details available on request). The questionnaire was administered through the Qualtrics™ platform and advertised via social media platforms, personal networks and the electronic newsletters of research partners (Dedoc and Breakthrough Type 1). Informed consent was obtained; ethical approval was granted by the University of the Sunshine Coast, Australia (A242046). Analyses and visualisation were performed using R software (v.4.2.0); p < 0.05 was considered statistically significant.

Of 218 respondents (n = 172, 78.9% female), 162 (74.3%) were PT1D and 56 (25.7%) were CCPT1D; five respondents partially completed the survey. The mean ± SD [range] age and diabetes duration of PT1D was 46.6 ± 15.5 [62] and 21.5 ± 15.4 [60] years, respectively; three respondents were aged <18 years. The age of CCPT1D was 46.8 ± 6.5 [28] years; the age and diabetes duration of the PT1D they provided care was 13.8 ± 5.7 [35] and 7.3 ± 4.1 [15] years. CCPT1D responses relate to the PT1D they care for.

Most respondents were born (n = 165, 75.7%) and currently living (n = 180, 82.6%) in Australia. In the previous 5 years, 145 (66.5%) had travelled internationally; for 113 respondents who detailed countries visited, 83 (73.5%) had travelled to Europe, 23 (20.4%) to Asia and 55 (48.7%) to ≥1 lower and middle-income countries. The United States of America (n = 83, 73.5%) and United Kingdom (n = 69, 61.1%) were popular travel destinations. The time spent overseas varied; 56.7 ± 75 [364] days for PT1D and 41.5 ± 58 [263] days for CCPT1D. Most (n = 96, 85%) travel was for pleasure (vs. business).

Before international travel, most (n = 146, 68.5%) respondents consulted with a healthcare professional (HCP); advice was also obtained from friends (n = 18, 8.5%), online sources (n = 77, 36.2%) and/or social media (n = 118, 55.3%). PT1D and CCPT1D differed in travel health knowledge, attitudes and practices (Figure 1). PT1D (vs. CCPT1D) were less likely to consult a doctor before travel (64.2% vs. 82.4%, p = 0.01), but more likely to check feet daily (66.2% vs. 29.4%, p = 0.001).

More than half (n = 112, 52.6%) of respondents reported having experienced difficulties going through airport customs/security (Table 1). Reasons for this included security staff being unfamiliar with T1D-related technology and requests to put diabetes-related technology through an x-ray machine. The related experience meant lengthy delays and subsequent attention. Procedures with airport customs/security and related experiences varied between airports, even within countries, creating a sense of apprehension and dread.

International medical consultations (n = 47, 22.9%) and T1D supplies (n = 52, 25.1%) were sometimes needed (Table 1); no consultations were directly attributable to acute T1D management problems. More PT1D (vs. CCPT1D) needed a medical consultation (p = 0.02), and no differences in outcomes were observed between those who had (vs. had not) indicated typically consulting an HCP before international travel.

Based on their experience of preparing for and undertaking international travel, 97 (47.8%) of 203 respondents wished that there had been greater support available; PT1D (vs. CCPT1D) were more likely to want greater support (52.9% vs. 31.3%, p = 0.01). Of these 97 respondents, 47 (48.5%) wanted improved processes relating to airport customs/security and T1D-related travel, including consistent airport procedures, security staff education, and/or the use of a universally accepted lanyard detailing a T1D diagnosis and security precautions to be followed.

In summary, study findings match those elsewhere, illustrating that PT1D, including children, are likely to travel internationally.^{1, 2, 5-7} Reported HCP consultation before international travel was also consistent,^{1, 5-8} as were difficulties experienced navigating airports and security,^{5, 7-11} and when overseas.^{1, 6, 7} Consensus guidelines should be developed and promulgated. Consideration should be given to evolving diabetes-related technologies, and how HCPs and diabetes-related organisations can best deliver guideline content in both preparatory and emergency contexts. Furthermore, the development and implementation of a lanyard detailing T1D should be a focus of key diabetes patient organisations; a positive example is the widespread adoption of the yellow and green hidden disabilities lanyard, now recognised in 240 airports across 30 countries and by 17 airlines worldwide.¹² Finally, while there is always risk that PT1D may have illness overseas, the implications of which can be dire, both our and others findings raise questions surrounding increased travel health insurance premiums (vs. the general population). Further research in this area is warranted.

Dr. Steven James, Chloe Tarlton and Dr. Judy Craft were involved in the study design, and Dr. Steven James and Dr. Jayanthi Maniam were involved in data analysis. All authors contributed to and approved the submitted manuscript.

This work was supported by a philanthropic grant received from the Helpful Foundation, Australia.

The authors have declared no conflicts of interest.